Basic Information
| Provider Information | |||||||||
| NPI: | 1053441725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILPOTT | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | M. ED, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 GRAND CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042953345 | ||||||||
| FaxNumber: | 3042953345 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 GRAND CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042953345 | ||||||||
| FaxNumber: | 3042953345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1598 | WV | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 1598 | WV | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 1598 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1598 | 01 | WV | WV LPC NUMBER | OTHER |